Download PDF - Field Exchange - Emergency Nutrition Network

News &Views
combination with oil and sugar. However, there
are a number of shortcomings with FBFs such
that they are not optimal for feeding moderately
malnourished children and need to be
improved and/or replaced by foods that better
meet their nutritional needs.
Presentations from WFP, UNICEF and
USAID described the various improvements
the agencies all plan to make to their fortified
blended flour products, e.g. increasing the
energy density, adding dairy products,
dehulling soybeans, possibly removing cereal
germ, changing the proportion of energy from
fat, improving the EFA and micronutrient
profiles.
Improvements and adaptations to lipidbased
nutrient supplements (LNS) and readyto-use
foods (RUFs) are also being made by the
members of the LNS Research Network
(supported by grants from the Bill and Melinda
Gates Foundation and with support of the
USAID- funded FANTA-2 Project) and Valid
International.
Papers on field research from Malawi (Prof
Ken Maleta, Blantyre College of Medicine),
China (Prof Chen Chunming, International Life
Science Institute), Niger and Sierra Leone (Dr
Susan Shepherd, MSF-Nutrition Working
Group) and Ghana (Prof Kathryn Dewey,
University of California, Davis) presented data
on the impact and outcomes of using
specialised products to treat and prevent MM in
different contexts. For example, in Malawi,
supplementary feeding of milk/peanut and
soy/peanut fortified spreads to treat moderately
wasted children resulted in slightly higher
recovery rates than feeding with CSB. In Niger,
a targeted MSF supplementary feeding
programme for moderately wasted children
using RUF had a 95% recovery rate. In Sierra
Leone, soy peanut fortified spread resulted in
higher weight gain and shorter treatment than
premix CSB-oil.
Consensus statements
• There is an urgent need to develop clear
terminology for the different specialised
foods used to treat moderate malnutrition.
• When it is expected that a new food product
will have at least equal impact on growth,
morbidity and micronutrient status
compared to an existing product (often a
FBF such as CSB or WSB), then it is permissible
to use this product in programmes for
feeding moderately malnourished children
provided that the product is acceptable to
the beneficiaries. In that case, it is important
to collect programme data to monitor the
impact of this new product on the time
needed for recovery of MM children, when
the product is used for treatment, or on the
occurrence of new cases of malnutrition if it
is used for prevention. Concurrently, the
efficacy of the new product should also be
assessed under carefully controlled circum
stances in the same or another area or country,
depending on local possibilities. Such
efficacy testing should include measures of
physiological, immunological, cognitive and
body compositional recovery as well as
simple weight gain.
• It is very likely that different types of
specialised foods and programme formats
(e.g. blanket or targeted, dietary coun
selling) will be used to treat, or prevent,
moderate malnutrition in the future,
depending on the context (security, prevalence
of malnutrition, general food security
conditions, etc). The next WHO meeting on
moderate malnutrition, which will focus on
programming issues, should endeavour to
develop algorithms for determining what
programme type and product to use in
different situations.
Research needs
Areas of uncertainty still exist with respect to
improving FBFs. These include: the impact of
dehulling and degerming of soy, maize and
wheat, addition of phytase and/or amylase to
improve nutrient availability and food acceptability,
maximum tolerable fibre content, the
minimal quantity of energy provided by fat to
ensure adequate energy intake, the
amount/proportion of milk required in the
formula, the possibility and efficacy of using
plant protein isolates, especially soy protein
isolates, as a possible substitute for dairy products.
There is also a question regarding whether
the anti-nutrient content of FBFs can be significantly
reduced by encouraging farmers to
produce crop types that have naturally lower
concentrations of anti-nutrients.
Agencies urgently need to collect impact
assessment data from the different products
(FBF, RUF, LNS, micronutrient powders) being
used to treat and prevent MM in different
contexts so that field agencies/governments
know which product to use in a given context.
The impact and outcome data for new products
need to be comparable across studies and
programme evaluation. Information on nonfood
context factors should also be collected
(e.g. programme incentives). The operational
advantages of some products/programme
types should be recorded (e.g. blanket distributions
may be easier in food insecure areas).
It is essential to collect information on the
costs of providing different types of specialised
products, complementary interventions, and
the means of distribution.
Recommendations of the meeting –
Next steps
The meeting made a number of recommendations
to move forward and to continue to
improve current programmes in the next few
years.
Establishment of a process to develop specifications
for food categories for moderately
malnourished children and validation of new
products for prevention and treatment of
moderate malnutrition in children.
Dr. Carlos Navarro-Colorado (Emergency
Nutrition Network) presented a description of a
generic approach to validate the efficacy of new
foods for moderate malnutrition. This would
need to be based upon clear classification of
different types of food supplements required
and the nutrient specifications for each category
of food supplement. Four stages of validation
were proposed: (i) analysis of composition and
processing, (ii) small scale clinical pilot, (iii)
field efficacy trial, and (iv) post-validation
monitoring. It would not be necessary to
conduct all four stages for all products.
The design of studies and validation of products
will face a number of challenges. These
include lack of baseline dietary information,
accounting for differences in the quality of
programme implementation, the need to
broaden and define outcome indicators beyond
anthropometry, and accounting for the fact that
an unknown proportion of moderately
malnourished children will recover spontaneously.
Another significant challenge will be
how to establish an institutional mechanism
and identify a lead agency for ensuring coordinated
validation of products.
A working group then examined how to
move forward and to set up a process of
improving existing food supplements and
ensure their efficacy is adequately evaluated.
Consensus statements
• A standing task force should be established
and led by WHO with appropriate UN
agencies and other technical experts to
develop specifications for specialised products,
in particular for moderately wasted
children, in a first step.
• A separate expert group should be established
to examine different endogenous food
components that have potential negative
effects and develop upper limits for these
anti-nutrients and toxins. One of the tasks
of this group would be to determine the
maximum acceptable level of different types
of dietary fibres and other potentially deleterious
natural constituents that can be
present in food supplements.
• There is a need for an independent standing
working group to assist national governments
and agencies to determine if newly
available products that are put onto the
market are appropriate and whether (a)
particular type(s) of product testing are
required before granting approval for their
use among specific target groups.
• The meeting recommended that this set of
activities should be initiated within the next
six months.
Research Needs
In the discussions, the meeting also identified
the need to estimate the level at which recovery
from moderate malnutrition occurs in absence
of supplementation so that this can be
accounted for in trials involving new products.
This can be achieved either by examining data
from previous studies where some children did
not receive any supplement or by taking as the
control group in intervention studies a group
receiving adequate dietary counselling but no
food supplement.
There is also a need to elaborate specific nonanthropometric
measures that can be used to
compare outcomes and product efficacy. This
will involve developing and strengthening field
friendly techniques for measuring outcomes
such as body composition, immunocompetence,
micronutrient status, renal concentrating
ability, physical activity level, sodium pump
function, intellectual development, etc.
Organisation of a second meeting on
improving programmes addressing the
management of moderate malnutrition
The focus of this technical meeting was dietary
requirements of MM children, so that programmatic
issues were not substantively addressed.
The WHO is planning a further technical meeting
on programming for MM children.
For more information, contact: Zita Weise-
Prinzo, WHO, email: weiseprinzoz@who.int
25